Telemedicine Consult for Shortness of Breath Due to Sympathetic Crashing Acute Pulmonary Edema

Audience This simulation is appropriate for senior and junior emergency medicine residents. Introduction Shortness of breath is a very common presentation in the emergency department and can range from mild to severe as well as a chronic or acute onset. In sympathetic crashing acute pulmonary edema (SCAPE), patients typically present with acute onset of dyspnea occurring within minutes to hours and have significantly elevated blood pressure.1 The condition of SCAPE falls into the spectrum of acute heart failure syndromes such as fluid overload pulmonary edema and congestive heart failure exacerbation.1 Educational Objectives At the completion of the simulation and debriefing, the learner will be able to: 1) recognize the physical exam findings and presentation of SCAPE, 2) utilize imaging and laboratory results to further aid in the diagnosis of SCAPE, 3) initiate treatments necessary for the stabilization of SCAPE, 4) demonstrate the ability to assist with the stabilization and disposition of a patient via tele-medicine as determined by the critical action checklist and assessment tool below, 5) interpret the electrocardiogram (EKG) as atrial fibrillation with rapid ventricular response (AFRVR), and 6) recognize that SCAPE is the underlying cause of AFRVR and continue to treat the former. Educational Methods This simulation was performed using a high-fidelity mannequin. In order to simulate the telemedicine aspect, the learner evaluated the patient using a video conferencing interface while the two confederates were present with the high-fidelity mannequin. A debriefing session was held immediately after the simulation. Research Methods The educational content was evaluated by debriefing and verbal feedback provided immediately after the case. Additionally, a survey was emailed to participants and observers of the case to provide qualitative feedback. Results Post-simulation feedback was overall positive with participants and observers. Participants and observers felt this was a safe and realistic simulation of SCAPE and provided them with the opportunity to practice rapid recognition and treatment of this condition. Discussion Sympathetic crashing acute pulmonary edema falls into the spectrum of acute heart failure disorders, and rapid recognition and stabilization is vital for the patient’s survival. This simulation case provided learners of all levels the chance to assess and treat a life-threatening condition with limited information in a safe and effective learning environment. The telemedicine component was used while conducting weekly didactics via zoom during the COVID-19 pandemic. Simulation is a large component of our didactic curriculum and implementing the telemedicine component into this case was worth the effort. It is important to familiarize our residents with telemedicine since we expect that it will become a larger part of the practice of emergency medicine in the future, allowing board-certified emergency medicine physicians to assist in providing care in rural emergency departments and smaller hospitals that may be staffed with less experienced providers. Topics Medical simulation, tele-medicine, pulmonary edema, respiratory distress, cardiac emergencies, resuscitation.

tele-medicine format of this simulation case was chosen because our weekly didactic sessions were moved to a video conferencing format due to the COVID-19 pandemic. In our region, tele-medicine is frequently used because there are many critical access hospitals in our predominantly rural state. This case will give the learner the ability to practice telemedicine and demonstrate the ability to assist in patient resuscitation without having direct patient contact (objective 4). It will also assess their ability to interpret an EKG (objective 5), but the learner should recognize that AFRVR is being caused by SCAPE and should be treated with respiratory support and nitrates instead of rate or rhythm control medications (objective 6).

Results and tips for successful implementation:
This simulation was written to be performed during virtual didactics while using the ZOOM video conferencing platform during the COVID-19 pandemic. In order to perform the telemedicine component, a laptop was placed on a table at the foot of the mannequin's bed. The laptop was logged into the ZOOM didactic session to allow the participant and observers to see the mannequin, cardiac monitor, and the two confederates. One second-year resident participated in the simulation case while the remainder of the residents and faculty observed. This format allowed us to demonstrate a scenario that simulates SCAPE and provides the stimulus needed during an emergent tele-medicine consult. To perform this simulation as written, we would recommend conducting the case over a video conferencing format with one to two learners and two confederates. The instructor and confederates should be with the high-fidelity mannequin and accessible over the video conference. This case could also be performed without the video conferencing format and could also be utilized as an oral board case. Learners were evaluated by the instructor(s) based on their ability to correctly diagnose and treat the patient.
Participant and observer feedback was overall very positive, and they did not recommend any significant changes to the case design or format. This case was initially performed during the COVID-19 pandemic while all didactic sessions were conducted via video-conferencing. Because of this, only one

Objectives:
At the completion of the simulation and debriefing, the learner will be able to: A 59-year-old male presents to a critical access hospital due to shortness of breath. He has a history of insulin dependent diabetes, atrial fibrillation, and hypertension. A nurse practitioner at the critical access hospital has initiated a telemedicine consult that the learner will conduct via teleconferencing video call. The patient will currently be hypoxic despite being on a nonrebreather for the past 10 minutes. The confederate practitioner will discuss the case with the learner and ask for additional help in management. The confederate should tell the learner the entire history and physical exam as well as treatments that have already been attempted. The learner should recognize that the patient is in sympathetic crashing acute pulmonary edema (SCAPE) and request that he be placed on BiPAP or CPAP and be given nitroglycerin bolus(es) and/or infusion. At the conclusion of the case, the patient should be transferred. This case can also be performed without the telemedicine component.

Background and brief information:
59-year-old male presents via private vehicle to a critical access hospital due to worsening shortness of breath. He has a history of insulin dependent diabetes, atrial fibrillation, and hypertension.
Initial presentation: 59-year-old male who presents with shortness of breath and appears to be in severe respiratory distress.
How the scene unfolds: The learner(s) is/are consulted via tele-medicine from a critical access hospital regarding a patient in severe respiratory distress due to SCAPE. The learners should ask the confederates about their initial assessment, interventions, and changes in the patient's initial presentation. The patient will have a nasal cannula at 2L/min; however, symptoms and vitals on presentation will be unchanged, which prompted the tele-medicine consult. Based on the patient's presentation, vitals, and physical exam findings, the learner(s) should suspect SCAPE and request an electrocardiogram, chest x-ray, BiPAP, and nitrates. If any other nonpositive pressure devices are used, the patient will not improve. If BiPAP and nitrates are not given within 5 minutes, the patient will become unresponsive, develop worsening hypoxia, and require intubation with mechanical ventilation. If appropriate medications and BiPAP are initiated in a timely manner, the patient will improve. The patient's initial electrocardiogram will be atrial fibrillation with rapid ventricular response (AFIB with RVR). The learner should recognize that the patient's underlying diagnosis (SCAPE) is the reason for AFIB with RVR and should stabilize the patient before treating the arrhythmia. If the arrhythmia is treated before stabilization, the patient's condition will further deteriorate at the discretion of the instructor until the pulmonary edema is treated. Patient is in severe respiratory distress on 2L/min NC, diaphoretic, sitting upright in a stretcher, and speaking 2-3 word sentences when the case begins.
History obtained from the provider via telemedicine.
If BiPAP/CPAP is not requested quickly, the patient will become unresponsive and more hypoxic requiring intubation. Requests ECG and CXR.

Requests labs.
If the patient is placed on BiPAP/CPAP, respirations and oxygen saturation should improve.
If patient is placed on any other form of oxygen support, the patient will not improve until BiPAP, CPAP, or intubation is performed.

Pathophysiology:
Typically occurs in the setting of uncontrolled or poorly controlled hypertension. It is a type of hypertensive emergency and also within the spectrum of acute heart failure syndromes (AHFS). While other AHFS develop over days to weeks, SCAPE develops within minutes to hours. The elevated systemic blood pressure leads to an increase in afterload. In part, this develops into poor peripheral perfusion and pulmonary edema. Due to decreased perfusion, there is a reflexive release of sympathetic mediators. Unfortunately, this sympathetic surge leads to peripheral vasoconstriction and pulmonary vasodilation, which further worsens afterload and pulmonary edema. Unlike other conditions associated with acute heart failure, patients with SCAPE are typically euvolemic or hypovolemic; therefore, diuretics typically will not improve this condition and have the potential to make it worse. Overall, the increased afterload leads to pulmonary edema as blood cannot efficiently leave the left side of the heart. This pulmonary edema makes the patient feel more dyspneic leading to further distress and more sympathetic activation. The repeated sympathetic activation causes additional vasoconstriction, particularly in the splanchnic vascular system. Pulmonary edema will once again further worsen due to this intravascular fluid shift from peripheral vasoconstriction and pulmonary vasodilation.

Diagnosis:
Because SCAPE must be recognized and treated rapidly, it is typically a clinical diagnosis. It should be recognized by rapid onset dyspnea over minutes to hours, systolic blood pressure greater than 180mmHg, and clinical and/or radiographic evidence of pulmonary edema. There are no specific laboratory values that confirm the diagnosis of SCAPE, although typically the BNP or pro-BNP will be elevated.

Treatments:
Despite the initial severity of SCAPE, invasive ventilation can often be avoided with rapid recognition and treatment with noninvasive ventilation (NIV) and systemic nitrates. Two types of NIV are bi-level positive airway pressure (BiPAP) and continuous positive airway pressure (CPAP). Noninvasive ventilation is able to utilize pulmonary dead space while reducing the preload and afterload by increasing intrathoracic pressure. Nitrates provide further benefit by also reducing the preload and afterload. Lower doses of nitrates will only provide venodilation, but as dosage is increased, they will also cause arteriodilation. If IV access is not immediately available, sublingual and topical nitrates can be utilized. Once IV access is 18 obtained, boluses of nitroglycerin can be given, typically 400-800 mcg every 5 minutes. This is then followed by a nitroglycerin infusion at 80-100 ug/min and then titrated to the desired effect. If recognized and treated rapidly, patients can be weaned off the infusion and BiPAP while in the emergency department. Sublingual captopril or IV enalapril can also be used to provide further afterload reduction as needed. Furosemide has shown poor evidence in improving SCAPE. In this subset of patients, it can have a negative effect because it activates the renin-angiotensin-aldosterone-system (RAAS) and sympathetic nervous system.

Atrial Fibrillation
Atrial fibrillation (AFIB) is the most commonly treated cardiac arrhythmia and characterized as an irregularly irregular ventricular rhythm and absence of P waves. It can be further classified as paroxysmal, persistent, long-standing persistent, and permanent. Presentations can vary from asymptomatic to palpitations, dizziness, syncope, nausea, and/or chest pain among many others. Treatment of AFIB in the emergency department is dependent on hemodynamic stability and risk stratification. In the hemodynamically unstable patient, synchronized cardioversion is the preferred treatment. Cardioversion without anticoagulation can also be performed if the arrhythmia has been present for less than 48 hours. Stable patients can initially be treated with intravenous rate control agents such metoprolol (lopressor) or diltiazem (cardizem). Metoprolol dosing is given as 5mg every two to five minutes for a maximum of 3 doses. If this is effective in reducing the heart rate to below 110 beats per minute (bpm), the patient is given oral metoprolol tartrate 25-100mg. Diltiazem is another first line option and is dosed at 0.25mg/kg IV. A second dose at 0.35mg/kg can be given if the first attempt does not reduce the heart rate to below 110 bpm. If both of these doses fail to achieve rate control, a diltiazem infusion ranging from 5-15mg/hr can be started.
Determining if there is an underlying cause such as SCAPE, pulmonary embolism, or myocardial infarction should also weighin on how AFIB is treated. Typically, as in this simulation, treatment of the underlying cause is ideal. In some studies, attempts at rate and/or rhythm control of AFIB when the patient has an acute medical illness may lead to a higher risk of adverse effects. 7

Telemedicine
Telemedicine is the process of delivering health services and information through an electronic means ranging from video conferencing to messaging. 8 It can allow board certified emergency medicine physicians to assist in providing care in rural emergency departments and smaller